vk; izek.

k i= gsrq vkosnu i=
1- vkonsd lEca/kh vko';d lwpuk ¼oSdfYid fcUnq dks ü ls p;u djsa½
1- izkFkhZ
dk uke
2- firk dk
uke
3- fuokl d- orZeku
LFkku dk irk
iw.kZ irk [k- LFkkbZ
irk
4- xkao 'kgj rglhy ftyk
5- tUe @ @ tUe mez
fnukad LFkku
6- fyax iq:"k efgyk oSokfgd fookfgr vfookfgr
fLFkfr
7- /keZ tkfr mitkfr
8 D;k vki@vkidk ifjokj jktLFkku ds ewy fuoklh gSA gk ugh
¡ a
9 D;k vki vk;dj nkrk gS gk ugh
¡ a
1 eksckbZy ftl ij izkFkhZ vkosnu ls lacaf/kr ,l-,e-,l- }kjk
0 ua- lwpuk pkgrk gSA
1 iSu dkMZ gksus dh n'kkk esa ,oa vk;dj foHkkx dh
1 isu dkMZ ua- fjVZu dh v|ru izfr layXu
djsaA
1 fVu uEcj gksus dh n'kk esa fVu ,oa okf.kfT;d dj foHkkx
2 ua- dh fjVZu dh v|ru izfr
layXu djsA
1 ifjokj ds lnL; o mudh okf"kZd vk; dk fooj.k
3
Øa- lnL; dk uke m lEca/k eq[;k dk;Z@O;olk; o mldh okf"kZd
l ez ls izd`fr vk;
1
2
3
 4
5
eS rLnhd djrk@djrh gWw fd mijksDr fooj.k esa esjh tkudkjh ,oa fo'okl
esa iw.kZr;k lgh o lR; gSA

fnukad%&
LFkku vkosnd ds
gLrk{kj
 izek.k i=
2- izek.k i=
¼1½ xokg
uke firk dk uke irk in dk uke

foHkkx dk uke ij dk;Zjr gw ,oa 'kiFk iwoZd c;ku djrk

gWw fd%&
izkFkh@izkFkh firk@ifr dk uke fuoklh
Z;ka

dks Hkyh izdkj tkurk gWw gS] blds vykok izkFkhZ ds ikl vk; dk
budh okf"kZd vk; dksbZ vU; L=ksr ugh gSA

¼gLrk{kj xokg@mRrjnk;h
O;fDr½

¼2½ xokg
uke firk dk uke irk in dk uke

foHkkx dk uke ij dk;Zjr gw ,oa 'kiFk iwoZd c;ku djrk

gWw fd%&
izkFkh@izkFkh firk@ifr dk uke fuoklh
Z;ka

dks Hkyh izdkj tkurk gWw gS] blds vykok izkFkhZ ds ikl vk; dk
budh okf"kZd vk; dksbZ vU; L=ksr ugh gSA

¼gLrk{kj xokg@mRrjnk;h
O;fDr½
 'kiFk i=

eS-------------------------------------------------------------------------------------------
--------------------iq=@iq=h
Jh------------------------------------------------------------------------------
mez------------o"kZ tkfr-----------------------fuoklh
--------------------------------------------------------rglhy---------------------------
ftyk----------------- jktLFkku 'kiFk iwoZd ?kks"k.kk djrk@djrh gWw fd
%&
1- ;g gS fd eq>s o esjs ifjokj dh okf"kZd vk; ¼o"kZ-------------½ ds
izek.k Lo:i mn?kks"k.kk djuh gSA
2- ;g gS fd eq>s o esjs ifjokj dh okf"kZd vk;¼o"kZ---------------½ ds
laca/k rF;kRed tkudkjh fuEukuqlkj gS%&
Øa- ifjokj ds lnL; uke O;olk; izkFkhZ ls okf"kZd
la laca/k vk;

3- ;g gS fd esjs ifjokj ds lnL;ksa }kjk /kkfjr Hkwfe o uks'kuy 'ks;j

ds /kkfjr dqy Hkwfe dk fooj.k fuEu izdkj ls gS%&
xkao dk rglhy [kljk jdck flafpr@vflaf okf"kZd
uke uEcj pr vk;

4- ;g gS fd esjs ifjokj esa vU; L=ksr

Øa la- vk; ds vU; L=ksr ¼Hkou lEifr]
fdjk;k] C;kt] is'kau] 'ks;j vkfn½

dqy@leLr okf"kZd vk; pj.k ¼isjk½ la- 2] 3] 4

5- ;g gS fd eSa 'kiFk iwoZd ?kksf"kr djrk@djrh gWw fd
mijksDrkuqlkj esjs ifjokj dh dqy@leLr okf"kZd
vk;-------------------------------:i;s vdsa
gh----------------------------------------------------:i;s gSA
6- ;g gS fd eSa 'kiFk iwoZd dFku djrh@djrk gWw] fd esjs o esjs
ifjokj ds fdlh lnL; us foxr esa mDr vafdr okf"kZd vk; izek.k i=
izkIr fd;k gSA
---2----
 A2A
7- ;g fd eSa 'kiFk iwoZd dFku djrk@djrh gWw fd ;g rF; esjh futh
tkudkjh esa gS] fd bl 'kiFk i= esa vafdr rF; ,oa 'kiFk iwoZd mn?
kksf"kr okf"kZd vk; dk xyr vFkok feF;k gksuk Hkkjrh; n.M
lafgrk ds vUrxZr n.Muh; vijk/k gSA

gLrk{kj
'kiFkxzfgrk@'kiFkxzfg=h
lR;kiu
eS------------------------------------------------------------------iq=@iq=h
Jh--------------------------------------------------------------------------mDr
'kiFkxzfgrk@'kiFkxzfgrh l'kiFk djrk@djrh gWw] fd bl 'kiFk i= dh ena
la- 1 ls yxk;r 3 ds lHkh rF; esjh futh tkudkjh ,oa fo'okl esa iw.kZr;k lgh
o lR; gS] bZ'oj esjh enn djsaA

gLrk{kj
'kiFkxzfgrk@'kiFkxzfgrh
gLrk{kj igpkudrkZ
1
2
¼uke]irk]LFkku o fnukad lfgr½
izek.khdj.k
 mijksDr 'kiFkdrkZ
uke-----------------------------------------------------------------------firk dk
uke--------------------------------------------------------------
tkfr---------------------------------------mez------------o"kZ
fuoklh--------------------------------rglhy-------------------------
ftyk----------------------us esjs le{k mifLFkr gksdj 'kiFkiwoZd mDrkuqlkj
vfHkopu fd;k gS] ftls izek.khd`r fd;k tkrk gSA izkFkhZ dh
igpku--------------------ds }kjk dh xbZ gSA

izek.khdj.k vf/kdkjh
gLrk{kj dk;Zikyd eftLVsªV@uksVsjh
uke o in eksgj

vk; 'kiFk i= ¼INCOME AFFDAVIT½

eSa ¼ekrk&firk½---------------------------------------------------------------------------------
iq=@iq=h Jh@Jherh------------------------------------------------------------------
fuokl-------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------
,oa
eSa ¼ekrk&firk½------------------------------------------------------------------------iq=@iq=h
Jh@Jherh---------------------------------------------------------------------------
fuoklh-----------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------
'kiFk iwoZd fuEu ?kks"k.kk djrk g¡w@djrh g¡w%&
1- ;g fd esjk@iq=@iq=h@vkfJr
Jh@dqekjh----------------------------------------------------------------------------------------------
--------------------
 laLFkk dk
uke------------------------------------------------------------------------------------------esa
i<+ jgk@jgh gS] ,oa dksbZ vU; Nk=o`fr@izksRlkgu jkf'ku izkIr ugh dj
jgk@jgh gSA
2- ;g fd 31 ekpZ 2012 dks lekIr gq, xr o"kZ ds layXu vuqlwph esa fn;s x;s fooj.k
ds vuqlkj esjh okf"kZd vk; ¼fo|kFkhZ ds ekrk&firk nksuks ukSdjh ;k
O;olk;jr gksus ij nksuks dh vk; dk ;ksx fy[ksa½ leLr L=ksr ¼osru] O;kikj]
fdjk;k] deh'ku] is'kau] tehu] tk;nkn vkfn½ ls :i;s---------------------------------
gSa] eSa ;g Hkh ?kks"k.kk djrk@djrh g¡w fd esjs LokfeRo esa tks lEifr gS og
vuqlwph esa fn;s x;s fooj.k ds vuqlkj gS rFkk eSusa esjs }kjk Hkqxrku fd;s x;s
djksa@midjksa rFkk Hkwfe jktLo dks lgh&lgh n'kkZ;k gSA esjs }kjk miyC/k
djok;s x;s rF;ksa vkSj vkadM+ks ds fy, vius vkidksa O;fDrxr :i ls mRrjnk;h
ekurk g¡wA
3- ;g fd mijksDr vuqPNsnksa esa fn;k x;k fooj.k esjh tkudkjh ds vuqlkj lR; gSA
4- ;g fd eSa ;g Hkh opu nsrk g¡w dh ?kks"k.kk esa fn;s x;s fooj.k ds vlR; ik;s
tkus ij eSa Nk=@Nk=ksa dks nh xbZ Nk=o`fr jkf'k dh nks xquk Hkqxrku
Hkkjr ds jk"Vªifr dks ykSVk nwaxk rFkk rF;ksa dh vlR;rk ds laca/k esa ljdkj
dk fu.kZ; vfUre ,oa ck/;dkjh gksxkA
5- ;g fd eSa vkns'k la- DOPT OM NO 36033/5/2004-ESTT(res) fnukad
14@10@2004 ds vuqlkj Øhehys;j esa ugh vkrk g¡wA

vfHkHkkod gLrk{kj
e; iwjk uke

firk ds
gLrk{kj----------------------------------------------
ekrk ds
gLrk{kj----------------------------------------------
 vk; izek.k i= gsrq vkosnu i=
izkFkh
dksVZ Qhl Z dk
LVkEi 2 :i;k QksVk
s
¼ikliks
1- vkonsd lEca/kh vko';d lwpuk ¼oSdfYid fcUnq dks ü ls p;u djsa½
1- izkFkhZ
dk uke
2- firk dk
uke
3- fuokl d- orZeku
LFkku dk irk
iw.kZ irk [k- LFkkbZ
irk
4- xkao 'kgj rglhy ftyk
5- tUe @ @ tUe mez
fnukad LFkku
6- fyax iq:"k efgyk oSokfgd fookfgr vfookfgr
fLFkfr
7- /keZ tkfr mitkfr
8 D;k vki@vkidk ifjokj jktLFkku ds ewy fuoklh gSA gk ugh
¡ a
9 D;k vki vk;dj nkrk gS gk ugh
¡ a
1 eksckbZy ftl ij izkFkhZ vkosnu ls lacaf/kr ,l-,e-,l- }kjk
0 ua- lwpuk pkgrk gSA
1 iSu dkMZ gksus dh n'kkk esa ,oa vk;dj foHkkx dh
1 isu dkMZ ua- fjVZu dh v|ru izfr layXu
djsaA
1 fVu uEcj gksus dh n'kk esa fVu ,oa okf.kfT;d dj foHkkx
2 ua- dh fjVZu dh v|ru izfr
layXu djsA
1 ifjokj ds lnL; o mudh okf"kZd vk; dk fooj.k
3
 Øa- lnL; dk uke m lEca/k eq[;k dk;Z@O;olk; o mldh okf"kZd
l ez ls izd`fr vk;
1
2
3
4
5
eS rLnhd djrk@djrh gWw fd mijksDr fooj.k esa esjh tkudkjh ,oa fo'okl
esa iw.kZr;k lgh o lR; gSA

fnukad%&
LFkku vkosnd ds
gLrk{kj
 izek.k i=
2- izek.k i=
¼1½ xokg
uke firk dk uke irk in dk uke

foHkkx dk uke ij dk;Zjr gw ,oa 'kiFk iwoZd c;ku djrk

gWw fd%&
izkFkh@izkFkh firk@ifr dk uke fuoklh
Z;ka

dks Hkyh izdkj tkurk gWw gS] blds vykok izkFkhZ ds ikl vk; dk
budh okf"kZd vk; dksbZ vU; L=ksr ugh gSA

¼gLrk{kj xokg@mRrjnk;h
O;fDr½

¼2½ xokg
uke firk dk uke irk in dk uke

foHkkx dk uke ij dk;Zjr gw ,oa 'kiFk iwoZd c;ku djrk

gWw fd%&
izkFkh@izkFkh firk@ifr dk uke fuoklh
Z;ka

dks Hkyh izdkj tkurk gWw gS] blds vykok izkFkhZ ds ikl vk; dk
budh okf"kZd vk; dksbZ vU; L=ksr ugh gSA

¼gLrk{kj xokg@mRrjnk;h
O;fDr½
 'kiFk i=

eS-------------------------------------------------------------------------------------------
--------------------iq=@iq=h
Jh------------------------------------------------------------------------------
mez------------o"kZ tkfr-----------------------fuoklh
--------------------------------------------------------rglhy---------------------------
ftyk----------------- jktLFkku 'kiFk iwoZd ?kks"k.kk djrk@djrh gWw fd
%&
1- ;g gS fd eq>s o esjs ifjokj dh okf"kZd vk; ¼o"kZ-------------½ ds
izek.k Lo:i mn?kks"k.kk djuh gSA
2- ;g gS fd eq>s o esjs ifjokj dh okf"kZd vk;¼o"kZ---------------½ ds
laca/k rF;kRed tkudkjh fuEukuqlkj gS%&
Øa- ifjokj ds lnL; uke O;olk; izkFkhZ ls okf"kZd
la laca/k vk;

3- ;g gS fd esjs ifjokj ds lnL;ksa }kjk /kkfjr Hkwfe o uks'kuy 'ks;j

ds /kkfjr dqy Hkwfe dk fooj.k fuEu izdkj ls gS%&
xkao dk rglhy [kljk jdck flafpr@vflaf okf"kZd
uke uEcj pr vk;

4- ;g gS fd esjs ifjokj esa vU; L=ksr

Øa la- vk; ds vU; L=ksr ¼Hkou lEifr]
fdjk;k] C;kt] is'kau] 'ks;j vkfn½

dqy@leLr okf"kZd vk; pj.k ¼isjk½ la- 2] 3] 4

5- ;g gS fd eSa 'kiFk iwoZd ?kksf"kr djrk@djrh gWw fd
mijksDrkuqlkj esjs ifjokj dh dqy@leLr okf"kZd
vk;-------------------------------:i;s vdsa
gh----------------------------------------------------:i;s gSA
6- ;g gS fd eSa 'kiFk iwoZd dFku djrh@djrk gWw] fd esjs o esjs
ifjokj ds fdlh lnL; us foxr esa mDr vafdr okf"kZd vk; izek.k i=
izkIr fd;k gSA
---2----
 A2A
7- ;g fd eSa 'kiFk iwoZd dFku djrk@djrh gWw fd ;g rF; esjh futh
tkudkjh esa gS] fd bl 'kiFk i= esa vafdr rF; ,oa 'kiFk iwoZd mn?
kksf"kr okf"kZd vk; dk xyr vFkok feF;k gksuk Hkkjrh; n.M
lafgrk ds vUrxZr n.Muh; vijk/k gSA

gLrk{kj
'kiFkxzfgrk@'kiFkxzfg
=h
lR;kiu
eS------------------------------------------------------------------iq=@iq=h
Jh--------------------------------------------------------------------------mDr
'kiFkxzfgrk@'kiFkxzfgrh l'kiFk djrk@djrh gWw] fd bl 'kiFk i= dh ena
la- 1 ls yxk;r 3 ds lHkh rF; esjh futh tkudkjh ,oa fo'okl esa iw.kZr;k lgh
o lR; gS] bZ'oj esjh enn djsaA

gLrk{kj
'kiFkxzfgrk@'kiFkxzfgrh
gLrk{kj igpkudrkZ
1
2
¼uke]irk]LFkku o fnukad lfgr½
izek.khdj.k
mijksDr 'kiFkdrkZ
uke-----------------------------------------------------------------------firk dk
uke--------------------------------------------------------------
tkfr---------------------------------------mez------------o"kZ
fuoklh--------------------------------rglhy-------------------------
ftyk----------------------us esjs le{k mifLFkr gksdj 'kiFkiwoZd mDrkuqlkj
vfHkopu fd;k gS] ftls izek.khd`r fd;k tkrk gSA izkFkhZ dh
igpku--------------------ds }kjk dh xbZ gSA

izek.khdj.k vf/kdkjh
gLrk{kj dk;Zikyd eftLVsªV@uksVsjh
uke o in eksgj
 'kiFk i=
eS--------------------------------------------------------------------------iq=@iq=h
Jh------------------------------------------------------------------------------mez------------o"kZ tkfr-----------------------
fuoklh--------------------------------------------------------rglhy---------------------------ftyk----------------- jktLFkku 'kiFk
iwoZd ?kks"k.kk djrk@djrh gWw fd%&
1- ;g gS fd eq>s o esjs ifjokj dh okf"kZd vk; ¼o"kZ-------------½ ds izek.k Lo:i mn?kks"k.kk djuh gSA
2- ;g gS fd eq>s o esjs ifjokj dh okf"kZd vk;¼o"kZ---------------½ ds laca/k rF;kRed tkudkjh fuEukuqlkj gS
%&
Øa- la ifjokj ds lnL; uke O;olk; izkFkhZ ls laca/k okf"kZd vk;

3- ;g gS fd esjs ifjokj ds lnL;ksa }kjk /kkfjr Hkwfe o uks'kuy 'ks;j ds /kkfjr dqy Hkwfe dk fooj.k fuEu izdkj
ls gS%&
xkao dk uke rglhy [kljk uEcj jdck flafpr@vflafpr okf"kZd vk;

4- ;g gS fd esjs ifjokj esa vU; L=ksr

Øa la- vk; ds vU; L=ksr ¼Hkou lEifr] fdjk;k] C;kt] is'kau]
'ks;j vkfn½

dqy@leLr okf"kZd vk; pj.k ¼isjk½ la- 2] 3] 4

5- ;g gS fd eSa 'kiFk iwoZd ?kksf"kr djrk@djrh gWw fd mijksDrkuqlkj esjs ifjokj dh dqy@leLr okf"kZd
vk;-------------------------------:i;s vdsa gh----------------------------------------------------:i;s gSA
6- ;g gS fd eSa 'kiFk iwoZd dFku djrh@djrk gWw] fd esjs o esjs ifjokj ds fdlh lnL; us foxr esa mDr vafdr
okf"kZd vk; izek.k i= izkIr fd;k gSA
7- ;g fd eSa 'kiFk iwoZd dFku djrk@djrh gWw fd ;g rF; esjh futh tkudkjh esa gS] fd bl 'kiFk i= esa vafdr
rF; ,oa 'kiFk iwoZd mn?kksf"kr okf"kZd vk; dk xyr vFkok feF;k gksuk Hkkjrh; n.M lafgrk ds vUrxZr
n.Muh; vijk/k gSA

gLrk{kj
'kiFkxzfgrk@'kiFkxzfg=h
lR;kiu
eS---------------------------------------------------------------------iq=@iq=h
Jh--------------------------------------------------------------------------mDr 'kiFkxzfgrk@'kiFkxzfgrh l'kiFk djrk@djrh
gWw] fd bl 'kiFk i= dh ena la- 1 ls yxk;r 3 ds lHkh rF; esjh futh tkudkjh ,oa fo'okl esa iw.kZr;k lgh o lR; gS]
bZ'oj esjh enn djsaA

gLrk{kj
'kiFkxzfgrk@'kiFkxzfgrh
gLrk{kj igpkudrkZ
1
2
¼uke]irk]LFkku o fnukad lfgr½
izek.khdj.k
mijksDr 'kiFkdrkZ uke-----------------------------------------------------------------------firk dk
uke--------------------------------------------------------------tkfr---------------------------------------mez------------o"kZ
fuoklh--------------------------------rglhy-------------------------ftyk----------------------us esjs le{k mifLFkr gksdj
'kiFkiwoZd mDrkuqlkj vfHkopu fd;k gS] ftls izek.khd`r fd;k tkrk gSA izkFkhZ dh igpku--------------------ds }kjk
dh xbZ gSA
izek.khdj.k vf/kdkjh gLrk{kj dk;Zikyd
eftLVsªV@uksVsjh
uke o in eksgj
 'kiFk i=
eS------------------------------------------------------------------------iq=@iq=h@ifRu Jh
----------------------------------------------------------tkfr------------mez--------------o"kZ fuoklh
-------------------------------------rglhy--------------------------ftyk--------------------dk jgus
okyk@okyh gWw tks fuEu dFku l'kiFk c;ku djrh@djrk gWw fd%&
1- ;g gS fd esjs o esjs ifjokj dh okf"kZd vk; ¼o"kZ 2012½ ds izek.k Lo:i mn?
kks"k.kk djuh gSA
2- ;g gS fd esjs o esjs ifjokj dh okf"kZd vk; ¼o"kZ 2012½ ds laca/k rF;kRed
tkudkjh fuEukuqlkj gS%&
uke laca/k O;olk; vk;

3- ;g gS fd esjs ifjokj ds lnL;ks }kjk /kkfjr Hkwfe@o uks'kuy 'ks;j ds /kkfjr dqy
Hwkfe xzke--------------------------------------rglhy------------------------------
ftyk-------------------------ds [kljk uaEcj --------------------------------------------------esa
flafpr@vflafpr d`f"k Hkwfe jdck-----------------------------gSDV;j ls okf"kZd
vk;---------------------------------------------------------------------------------gSA
4- ;g gS fd esjs ifjokj esa vU; L=ksrks ls vk; tSls Hkou lEifr fdjk;k] C;kt] is'ku]
'ks;j] E;qPoy Q.M vkfn ls vk; okf"kZd vk;---------------------------------------:i;s gSA
5- ;g gS fd eSa 'kiFk iwoZd c;ku djrk@djrh gWw] mijksDrkuqlkj esjs ifjokj dh
dqy@pj.k iSjk ua- 2] 3] 4 dk ;ksx leLr okf"kZd vk;-------------------------------------:i;s
vdsa gh--------------------------------------------------------------:i;s dh gSA
6- eSa 'kiFk iwoZdj c;ku djrk gWw fd esjs ifjokj ds fdlh Hkh lnL; us fox res
mDr vafdr okf"kZd vk; ls fHkUu vk; fdlh iz;ksxukFkZ ugh n'kkZ;h gS] rFkk u gh bl
ckcr dksbZ vk; izek.k i= izkIr fd;k gSA
7- eS 'kiFk iwoZdj ck;u djrk gWw fd ;g rF; esjh tkudkjh eas gS] fd 'kiFk i= esa
vafdr rF; ,oa 'kiFk iwoZd mn?kksf"kr okf"kZd vk; dk xyr vFkok feF;k gksuk
Hkkjrh; n.M lfgrk ds vUrxZr n.Muh; vijk/k gSA
8- eS 'kiFk iwoZd c;ku djrk gWw fd mDr vk; izek.k i= eq>s esjs
iq=@iq=h-------------------------------------------------------------ds fy;s vko';d gSA

gLrk{kj 'kiFkxzfgrk
izekf.kdj.k %&
eSa mDr 'kiFk xzfgrk l'kiFk izekf.kr djrk gWw fd bl 'kiFk&i= dh en la[;k 1 yxk;r 4
ds lHkh rF; esjh futh tkudkjh esa iw.kZr;k lR; o lgh gS] bZ'oj esjh enn djsaA
fnukad%&11@09@2012-
LFkku%& nkarkjkex<+ gLrk{kj
'kiFkxzfgrk